Preferences for Everyday Living Inventory (PELI) Nursing Home Version (PELI-NH-Full) Resident: Room Number: Interviewer: Date: Instructions to the Interviewer 1. Introduce yourself to the resident: Hello Mr./Mrs./Ms./Dr.. My name is (name), and I am the (position) here at (community). How are you today? 2. Describe what you are going to ask the person to do: This conversation is to help us get to know you better. The reason I m asking you these questions is that the staff here would like to know what s important to you. This helps us plan your care around your preferences. If you are uncomfortable with any question, please let me know. Feel free to not answer that question. Do you have any questions? 3. Explain how the interview works: I am going to ask you questions about your preferences. I would like to know what your preferences are right now. Some of the questions may ask about things you feel you can no longer do by yourself, but I d like to know if these activities would be important to you if you could do them with assistance or find a way to do it." NOTE TO INTERVIEWER: Take out the response card that reads: Very Important, Somewhat Important, Not Very Important, Not Important at All or Important, But Can t Do, No Choice and place it in front of the resident. 4. Explain the response choices: I am going to ask you whether an activity is important to you or not. I would like you to answer this question either Very Important, Somewhat Important, Not Very Important, Not Important at All or Important, But Can t Do, No Choice. For example, if the question is How important is it to you to watch TV? you decide what answer best fits how important watching TV is to you. [Show response options to resident]: You could answer Very Important, Somewhat Important, Not Very Important, Not Important at All or Important, But Can t Do, No Choice. Do you have any questions? NOTE TO INTERVIEWER: Any time the respondent states that an activity is Not Very Important or Not Important at All, simply check off that box and go to next item. NOTE TO INTERVIEWER: If a resident responds that they can t do an activity, first ask, Why can t you do it? Write resident s response verbatim in the notes section. Select Important, But Can t Do, No Choice when the resident indicates that the topic is important, but that he or she is physically unable to participate, or has no choice about participation while staying in the nursing home. 5. When to use alternative response items: If resident does not respond or says I don t know, or if the question is not applicable, check off No Response/NA. 6. Explain the nested questions: Once you have answered how important a preference is to you, I will ask you for details about your preference. 1
NOTE TO INTERVIEWER: When asking questions nested under each preference item, ask the openended question first, and write down the resident's response. If the resident cannot answer the question or provide the details about their preference, you can then read them the list of prompts to help them identify the specifics of what they like. If the resident answers with specific information about what they like, then skip the prompts and go to the next nested question or PELI item. 7. When to stop the interview: a. It is not necessary to do the entire inventory in one session. If the resident becomes fatigued, offer to stop the interview and return at another time. Make an appointment with the resident and leave a card with the time and date of the next interview. b. If the resident says they would not like to answer any more questions, respect the resident's wishes and discontinue the interview. Mark the interview as incomplete and try to interview a family member, friend or staff person who knows the resident well. c. If residents give more than five (5) Non-Responses in a row, stop the interview and ask the questions of a family member or staff person instead. 2
Detailed Preference Interview Resident Name: Interviewer Name: Date: I am going to ask you questions about your preferences. I would like to know what your preferences are right now. Some of the questions may ask about things you feel you can no longer do by yourself, but I d like to know if these activities would be important to you if you could do them with assistance or find a way to do it. Q01. How important is it to you to choose what name you would like me to use when I greet you? 1a. What name would you like me to use when I greet you? First name: Mr./Mrs./Ms./Dr.: Nickname: Other: Q02. How important is it to you to choose when to get up in the morning? 2a. What time do you usually like to get up in the morning? Between 5-6 am 6-7 am 7-8 am 8-9 am After 9 am Q03. How important is it for you to follow a routine when you wake up in the morning? 3a.What is part of your morning routine? Relax in bed Watch TV Brush teeth Cigarette Drink coffee/tea Listen to radio Bathe/wash-up Comments on order of routine: 3b.Would you like to stay in bed before rising? Yes o 3c. If Yes, how long do you like to stay in bed before rising? Get up right away Less than 15 mins 15-30 mins 31-45 mins Over 45 mins Depends on: Other: 3
Q04. How important is it to you to choose how often to bathe? 4a. How often would you like to bathe? Q05. How important is it to you to choose what time of day to bathe? 5a. What time of day do you like to bathe? Morning Evening Afternoon Night Other: at all (4) Q06. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? (MDS 3.0, F0400C) 6a. What type of bathing do you prefer? Tub Bath Sponge Bath Shower Bed Bath Comments on order of routine: Yes o -15 mins -20 mins -30mins 6c. Would you like a certain level of lighting when you bathe? No How bright do you like the lights: 6d. Would you like a certain room temperature when you bathe? o Which room temperature do you like: -65 degrees F) -75 degrees F) >75 degrees F) 4
6e. Would you like to listen to something when you bathe? o Which do you like to listen to when you bathe: Q07. How important is it to you to choose what clothes to wear? (MDS 3.0, F0400A) Important, but can t do, no 7a. What do you usually like to wear for the day? 7b. What do you like to wear to sleep? wear? wearto? to?sleep? 7c. What jewelry do you like to wear? wear? wearto? to?sleep? 7d. Do you like to a carry a: wear? wearto? to?sleep? 7e. Would you like your clothes arranged in a certain way? Yes No wear? wearto? to?sleep? 7f. If so, how would you like your clothes arranged? wear? wearto? to?sleep? Q08. How important is it to you to choose how to care for your mouth? 8a. What do you like to do to care for your mouth? Brush teeth Brush tongue Floss Clean/soak dentures Other: (How often? ) Q09. How important is it to you to choose how often you care for your nails? 9a. How often do you like to care for your nails/have your nails cared for? Daily Weekly Every other week Monthly 5
Q10. How important is it to you to choose how to care for your hair? 9b. What do you like to do to care for your nails/have your nails cared for? Cut/clip cuticles File nails with emery board Use nail finish/treatments (Type/Brand: ) Polish nails (Type/Brand/Color: ) 10a. How do you like to care for your hair? Shaving Plucking brows/face Hair coloring Hair cut Comb/brushing Hair styled Shaving legs Using styling products (Type: ) (Brand: ) Other: Q11. How important is it to you take a nap when you wish? 11a. When do you usually like to take a nap? Morning Evening/night Afternoon When I want response (9) Q12. How important is it to you to set up your own room the way that you want it? 12a. How do you like to set up your room? Arranged nightstand/bed table Arrange chairs Arrange closet Arrange bed/dresser Arrange walker/wheelchair Comments on order of routine: 12b. Would you like to display/decorate things in your room? No If yes, what things would you like to decorate your room with? Personal keepsakes Photos Holiday decorations Pictures/art Decor Curtains Other: 6
12c. Would you like to keep certain things near your bed? Yes o 12d. Which items do you like to keep by your bed? Clock Telephone Tissues Eye Glasses Lamp/Light Other: Q13. How important is it to you to take care of your personal belongings or things? (MDS 3.0, F0400B) 13a. What personal belongings do you prefer to take care of yourself? Q14. How important is it to keep your room at a certain temperature? Important, but can t do, no 14a. At what temperature do you like to keep your room? Average (69-72 degrees) On the warm side (>72 degrees) On the cool side (<69 degrees) Q15. How important is it to you to adjust the lighting in your room? 15a. What lighting level do you prefer during the day? Dim Moderate Bright 15b. Would you like to be able to adjust the blinds during the day? No If yes, do you like the keep the shades: Opened Closed It Depends: 7
Q16. How important is it to you to choose your own bedtime? (MDS 3.0, F0400E) 16a. What time do you like to go to bed? PELI-NH Revised 3/18/2016 Earlier than 7 pm 7-9 pm 9-10 pm 10-11 pm 11-midnight After midnight Q17. How important is it to follow a routine when you go to bed? 16b. How many hours of sleep do you like at night? 17a. Tell me about your bedtime routine: 17b. What activities do you like to do as part of your bedtime routine? Putting on pajamas Pray Have a snack Reading Listen to radio Watch TV Brush teeth Wash up Pick out clothes for the next day Other: Q18. How important is it to you to set up your bed for comfort? 18a. How do you like to set up your bed for comfort? 18b. Which things are important to you in setting up your bed for comfort? Position/fluff up the pillows Position pillow under limb # of pillows ( ) # of covers ( ) Change the room temperature Adjust bed height/settings Open bedroom door Shut bedroom door Nightlight on Listen to music ( ) Tuck blankets Loosen blankets Close curtains Open windows 8
Q19. How important is it for you to choose your medical care professional? 19a. What professionals do you like to see for medical care? PELI-NH Revised 3/18/2016 Physician Nurse Practitioner Physician s Assistant Chiropractor Acupuncturist Message Therapist Hypnotherapist Faith Healer Other: 19b. Would you like to continue to see your regular doctor? o If yes: Professional name: Professional specialty: Professional name: Professional specialty: Q20. How important is it to you to choose whether your daily caregiver is male or female? but can t do, no 20a. Which gender caregiver do you like for personal care (e.g., showering, dressing, toileting): Female Male No Preference Q21. How important is it to you that your daily caregiver knows your needs when going to the bathroom? 21a. What would you like your daily caregiver to know about your needs when going to the bathroom? 21b. Which bathroom needs would you like your daily caregiver to know about? How often I use the bathroom Where I like to use the bathroom Type of cleansing I like Type of assistance I need Use of stool softeners, suppositories, laxatives 9
Q22. How important is it to you to drink alcohol on occasion? 22a. What kind of alcohol do you like to drink on occasion? Wine Beer Hard liquor Mixed drinks Other: 22b. On what occasions do you like to drink alcohol? Special occasions Holidays Parties Dinner Bedtime Other: Q23A. Do you use tobacco products? If no, skip to Q24. If yes, continue to Q23B. Q23B. How important is it to you use tobacco products? 23b. If yes, which tobacco products do you use? Cigarettes Cigars Pipe Chewing tobacco Other: 23c. Where do you like to use tobacco products? 23d. When do you like to use tobacco products? Q24. How important is it for you to have regular contact with family? but can t do, no 24a. What family do you enjoy regular contact with? Name/Relationship: How often: Name/Relationship: How often: Name/Relationship: How often: 10
24b. With which people would you enjoy regular contact? 24c. Are there family with whom you prefer not to have contact? Yes No Name/Relationship: Name/Relationship: 24d. Which ways do you like to keep in regular contact with family? Visits in person Talking on the phone Email Sending and getting cards/letters Being intimate with your spouse or other Other: Q25. How important is it to you to have regular contact with friends? Very important (1) Somewhat important (2) Important, but can t do, no 25a. With what friends do you enjoy regular contact? Name/Relationship: How often: Name/Relationship: How often: 25b. With which friends do you enjoy regular contact? Other residents Friends Other: 25c. Which ways do you like to keep in regular contact with them? Visits in person Talking on the phone Email Sending and getting cards/letters Other: 11
Q26. How important is it to you to choose who you would like involved in discussions about your care? (modified MDS 3.0, F0400F) 26a. Once every 3 months there is a meeting of staff to help plan your care. Would you like to attend the meeting? Yes No 26b. Which people would you like involved in discussions about your care? Spouse Children Brother Daily caregiver Social worker Significant other Grandchildren Sister Nurse Doctor Friends: Other: 26c. Which areas of your care do you like to discuss? Q27. How important is it to you to do what helps you feel better when you are upset? 27a. Which things help your feel better when you are upset? comedy Relax Focus on how to solve the problem Think about happier times Not thinking about what upset you Other: 12
Q28. How important is it to you to talk to a mental health professional if you are sad or worried? 28a. Which professionals do you prefer talking to when you are sad or worried? 28b. Do you prefer medication rather than talking to someone when you are upset? Yes No Q29. How important is it to you to have the staff show that they care about you? 29a. Which ways would you like staff to show that they care about you? Holding your hand Giving a hug Saying something nice Joking with you Smiling nice tone of voice Q30. How important is it for you to have staff show you respect? 30a. In which ways do you like the staff to show you respect? Thanking you you need Honoring your feelings Listening to you Other: 13
Q31. How important is it for you to be able to use the phone in private? (MDS 3.0, F0400g) PELI-NH Revised 3/18/2016 31a. Where do you like to use the phone in private? Bedroom Other: Q32. How important is it to you to have privacy? 32a. Which of these activities do you like to keep private? Getting dressed/ changing clothes 32b. Which information do you like to keep private? Q33. How important is it to you to lock things up to keep them safe? (modified MDS 3.0, F0400H) 33a. What things do you like to keep locked up? Other: 33b. Which places do you like to lock things to keep them safe? Electronics A safe Other: 14
Q34. How important is it to you to be involved in choosing your roommate? PELI-NH Revised 3/18/2016 34a. Which of the following is important to you when choosing a roommate? Age How long they have lived here Keeps area clean Does not wear perfume Keeps lighting level low TV habits: Hearing ability Hygiene (body odors, gas, etc.) Not a smoker Quiet/keeps noise level low Level of disability Personality/character traits: Quiet Social Active Polite Not racially prejudiced Q35. How important is it to you to choose what you eat? 35a. What are your favorite foods for: Breakfast: Lunch: Supper: Favorite drinks: Condiments: Foods I dislike: 35b. Do you have certain ethnic or cultural food preferences? Yes No Q36. How important is it for you to choose when you eat? no 36a. When do you prefer to eat: Breakfast: Lunch: Dinner: Whenever I am hungry 36b. How much time do you usually like to spend eating a meal? 15
Q37. How important is it to you to choose where to eat? 37a. Where do you like to eat while you are here/in a nursing home? In your room In the dining room In the cafeteria At restaurants (How often: ) (9) Q38. How important is it to you to have snacks available between meals? 38a. Which of the following foods do you like to snack on? important at all (4) 38b. When do you like to snack? Q39. How important is it for you to eat at restaurants? 39a. Which kind of restaurants do you like? (Write name of favorite restaurant: ) 16
Q40. How important is it to you to order take-out food? 40a. Which kind of take-out food do you like to order? all (4) Pizza Wings Fish fry Italian Chinese Hamburgers BBQ chicken Japanese Q41. How important is it to you to spend time by yourself? 41a. In which ways do you like to spend time by yourself? 41b. In which places do you like to spend time by yourself? Q42. How important is it to you to spend one-on-one time with someone? 42a. Which people do you like to spend one-on-one time with? Not very important (3) 42b. What do you like to do with someone one-on-one? 17
Q43. How important is it to do things with groups of people? (MDS 3.0, F0500E) PELI-NH Revised 3/18/2016 43a. What do you like to do with groups of people? 43b. Which type of person do you enjoy in a group? Not very important (3) Friends Roommate Other residents Family members 43c. How many people do you like when doing things in a group? Q44. How important is it to you to meet new people? 44a. In which ways do you like to meet new people? Q45. How important is it to you to be a member of a club? 45a. Which kind of club(s) did you enjoy in the past? no Book club Card club Glee club Computer club 18
45b. What kind of clubs do you enjoy now? Book club Card club Glee club Computer club Q46. How important is it to be around children? 46a. What children do you enjoy doing activities with? Grandchildren Great Grandchildren School groups Other residents visitors all (4) ) 46b. What activities involving children do you enjoy? Watching them play Playing with them Talking with them Teaching them Q47. How important is it to you to volunteer your time? 47a. Have you volunteered your time in the past? Yes No 47b. If yes, which ways have you volunteered your time in the past? all (4) Reading with/teaching children Coaching a sports team unteer activities Shopping for other people Helping people learn the computer 47c. How do you like to volunteer your time now? Reading with/teaching children Coaching a sports team raising Shopping for other residents Helping people learn the computer 19
Q48. How important is it to participate in religious services or practices? (MDS 3.0, Section F, F0500H) 48a. What is your religious background? Important, but can t do, no 48b. Do you belong to a religious organization? Yes No 48c. If yes, which organization do you belong to? 48d. If so, what is the name? 48e. Which religious services or practices do you like? Read/study the Torah/Bible/Koran/other Attend religious services Pray/meditate Watch service on TV ones? ) Q49. How important is it to you to participate in your cultural traditions? 49a. In which cultural traditions do you like to participate? Eating traditional food Celebrations Holidays Religious traditions 20
Q50. How important is it to you to reminisce about the past? 50a. Which topics do you like to reminisce about?? Family Pets Friends TV shows Hobbies Non response (9) 50b. With which people would you like to reminisce?? 50c. Do you like to reminisce with a group of people? Yes No Q51. How important is it to you to give gifts? 51a. To which people would you like to give gifts? important at all (4) 51b. Which kind of gifts do you like to give? 51c. Is it important to you to give gifts on holidays or special occasions? Yes No If yes, on which holidays or special occasions would you enjoy giving gifts? 21
Q52. How important is it to you to go shopping? 52a. At which stores do you like to shop? store important at all (4) Write names of favorite stores if given: Q53. How important is it to you to do things away from here? 53a. Which kinds of things would you like to do away from here? to the theater 53b. How long do you like to spend away from here? 53c. Whom do you like to be with if you were away from here? Q54. How important is it to you to attend entertainment events? 54a. Which entertainment events did you enjoy in the past? (4) 22
Q55. How important is it to you to go outside to get fresh air when the weather is good? (MDS 3.0, Section F, F0500G) 55a. In which type of weather do you like to go outside? PELI-NH Revised 3/18/2016 55b. Which things do you like to do outside when the weather is good? 55c. How many times do you like to go outside in a week? -3 times a week -5 times a week Q56. How important is it to you to take care of the place you live? 56a. Which tasks do you like to do to care for the place you live? laundry Non response (9) Q57. How important is it to you to do outdoor tasks? 57a. Which tasks do you like to do to care for the place you live? Important, but can t do, no 23
Q58. How important is it to you to be around animals such as pets? (MDS 3.0, Section F, F0500C) 58a. Which kind of animals do you like to be around? 58b. Which type of contact do you enjoy with animals? 58c. Are you allergic to animals? Yes No If yes, what kind? Q59. How important is it to you to keep up with the news?(modified MDS 3.0, F0500D) 59a. Which ways do you like to keep up with the news? can t do, no with another person Q60. How important is it to you to learn about topics that interest you? 60a. Which topics would you like to learn more about? do, no Eye problems Hearing problems 60b. Which ways would you like to learn about topics that interest you? professional 24
Q61A. Do you have difficulties reading due to eyesight? If no, skip to Q61C. If yes, continue to Q61B. Q61B. (If yes) I'd like to know if these activities would be important to you if you could do them with assistance or find a way to do it. How important is it to you to have reading options for low vision available to you? (modified MDS 3.0, F0500A) 61d. Which reading options would you like available? 61e. Which materials do you like to read? 61f. Would you like to be a member of a book club? Yes No 61g. Would you like to read on an electronic tablet, e-reader, or notebook? Yes No Go to question Q62. Q61C. (If no) How important is it to you to have reading materials available to you? (modified MDS 3.0, F0500A) 61e. Which materials do you like to read? 61f. Would you like to be a member of a book club? Yes No 61g. Would you like to read on an electronic tablet, e-reader, or notebook? Yes No 25
Q62. How important is it to you to exercise? 62a. Which types of exercise do you like? -ups Q63. How important are sports to you? 63a. Which types of sports have you enjoyed in the past? Not very important (3) 63b. Which types of sports would you like now? 63c. Which ways do you like to participate in sports? 26
Q64. How important is it to you to play games? 64a. Which types of games do you like to play? games important at all (4) Video games (e.g. Wii) 64b. With which people do you like to play games? Q65. How important is it to you to take care of plants? 65a. In which ways do you like to care for plants? about plants 27
Q66. How important is it to you to be involved in cooking? 66a. Which ways do you like to be involved in cooking? Attending cooking class Q67. How important is it to you to watch or listen to TV? 67a. Which type of TV programs do you like to watch? Write names of favorite programs, if given: Q68. How important is it to you to watch movies with other people? 68a. Which type of movies do you like to watch with other people? 68b. Which places do you like to watch movies with other people? room 68c. Which people do you like to watch movies with? other Other: 28
Q69. How important is it to you to listen to music you like? (MDS 3.0, Section F, F0500B) 69a. Which kinds of music do you like? can t do, no Other: 69b. Do you have a favorite era of music? Yes No If yes: 69c. Do you have favorite musicians/musical groups? Yes No If yes: 69d. Which ways do you like to listen to music? Q70. How important is it to you to use the computer? 70a. Which activities would you like to do on the computer? important at all (4) 70b. Would you like to learn about using the computer? Yes No If yes, what would you like to learn? 29
Q71. How important is it to you to do your favorite hobbies? 71a. Which kinds of hobbies do you like? important at all (4) Q72. How important is it to you to do your favorite activities? (MDS 3.0, F0500F) 72a. What are you favorite activities? 72b. With whom would you like to do your favorite activities? Non response (9) 30
1=Very Important PELI-NH Revised 3/18/2016 2=Somewhat Important 3=Not Very Important 4=Not Important at All 5=Important, But Can't Do, No Choice 31